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Jones v. Commissioner of Social Security

United States District Court, Second Circuit

August 22, 2013

MICHAEL WAYNE JONES, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

OPINION AND ORDER

JESSE M. FURMAN, District Judge.

Plaintiff Michael Wayne Jones brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"), Title 42, United States Code, Section 405(g), challenging a final decision of the Commissioner of Social Security (the "Commissioner") finding him ineligible for Supplemental Security Income ("SSI") disability benefits as of October 15, 2010. Both parties have moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons discused below, the Court concludes that Plaintiff was afforded a full and fair hearing, that the Administrative Law Judge's ("ALJ") decision is free of legal error, and that it is supported by substantial evidence in the record. Accordingly, the Court grants the Commissioner's motion for judgment on the pleadings and denies Plaintiff's cross-motion.

PROCEDURAL HISTORY

On September 19, 2008, Plaintiff filed an application for disability insurance benefits under the Social Security Act, alleging that he was disabled as of April 18, 2007. (AR 8) Following the Commissioner's denial of Plaintiff's application on initial administrative review, Plaintiff requested an administrative hearing. ( Id. ). On June 25, 2010, ALJ Katherine Edgell conducted a hearing, which Plaintiff attended with his counsel. ( Id. ). At the hearing, the ALJ considered, among other things, Plaintiff's testimony and the testimony of physicians Dr. Deepak Vasishtha, Dr. Walter Nieves, Dr. Barbara Akresh, and Dr. Lawrence Schul man. After reviewing the case de novo, the ALJ found that Plaintiff was not disabled (AR 8-19), which became the Commissioner's final decision when the Appeals Council denied Plaintiff's request for review on June 11, 2012 (AR 1-3). See Brown v. Apfel, 174 F.3d 59, 61 (2d Cir. 1999).

BACKGROUND

The following facts are taken from the administrative record and are undisputed. Plaintiff was born in Alabama in 1966 and has a tenth-grade education. (AR 24, 26). From 1998 to 2007, Plaintiff worked in a warehouse, loading and unloading boxes weighing up to sixty pounds (AR 26-27, 121-22). Before that, he worked as a maintenance worker in a job that required him to lift up to forty pounds in weight. (AR 28, 121).

Plaintiff alleges he became disabled on April 17, 2007, after injuring his back at work. X-rays taken of Plaintiff's lumbar spine, left hip, femur, and knee on the day after his accident showed no fracture, dislocation, or other abnormality. (AR 280-81). On April 20, 2007, Plaintiff was examined by Vasishtha, a physical medicine and rehabilitation physician. (AR 240-44). At that time, Plaintiff was five feet eleven and one-half inches tall and weighed 280 pounds, which Vasishtha described as "morbidly obese." (AR 241). Plaintiff told Vasishtha that, since his accident a few days earlier, he had experienced lower back pain that radiated down his left leg and decreased sensation to light touch over portions of his body. (AR 240-41). Vasishtha observed that Plaintiff had a slow, stiff gait with a limp and that his lumbar spine forward flexion, extension, and lateral flexion were all reduced. (AR 242). His motor strength for his upper extremities and right lower extremity were normal at 5/5, but his lumbar spine motor strength was reduced to 4/5. ( Id. ). Vasishtha found that Plaintiff had acute lumbar disc herniation, acute left-sided radiculitis, and an acute lumbar sprain/strain. (AR 243). He noted that Plaintiff "has significant difficulty ambulating without pain [for] more than half [a] city block[, ]... has significant difficulty climbing up and down [stairs] and negotiating curbs and sidewalks, " and has "poor balance... from pain in the left lower extremity and the back." (AR 243). He recommended further testing and prescribed the medications Medrol and hydrocodone. (AR 243-44).

Vasishtha examined Plaintiff approximately one month later. At this examination, he noted that after a course of physical therapy and anti-inflammatory and pain medication, Plaintiff had made some improvements, but still had difficulty walking, even with a cane. (AR 237-39). Vasishtha also opined that Plaintiff was "totally disabled, " and he recommended that he not return to his job, which required heavy lifting and exertion. (AR 239). A lumbar spine magnetic resonance imaging ("MRI") from May 27, 2007, revealed a "normal study, " with no sign of disc herniation, canal stenosis, or focal left lateral recess or left neural forami nal encroachment. (AR 215). At Plaintiff's next visit on June 20, 2007, Vasishtha performed an electrodiagnostic study that revealed "evidence of a bilateral L5-S1 radiculopathy." (AR 245-49).[1] From June through August 2007, Vasishtha continued to see Jones approximately once a month. Vasishtha repeated, essentially, his previous clinical findings and continued to diagnose Plaintiff with herniated lumbar discs, notwithstanding the negative MRI. (AR 227-30, 231-33, 234-36).

On July 25, 2007, Plaintiff was admitted to Nyack Hospital for three days because he was complaining of chest pain and palpitations. (AR 172-76, 179-211). Plaintiff noted that he had been "somewhat noncompliant" with his hypertension medication. (AR 173, 175, 183). The attending cardiologist diagnosed Plaintiff with atypical chest pain, malignant hypertension, and morbid obesity, among other things (AR 175, 189, 191), but Plaintiff's tests, which included an electrocardiogram and an echocardiogram, were negative (AR 179-82, 192-211).

On August 1, 2007, Schulman, an orthopedist, examined Plaintiff in connection with his Workers' Compensation claim. (AR 263-65). Plaintiff complained of persistent, severe pain in his lower back that radiated down his left lower extremity, as well as marked tenderness over the left lumbar paravertebral areas and over the lower facet joints and left sacroiliac joint. (AR 263). He also reported that he could stand or sit for only twenty minutes at a time, had limited lumbar range of motion, and could walk only up to one half of a city block. ( Id. ). Plaintiff also displayed a sensory deficit to pinprick and light touch over the left L5 dermatome. ( Id. ). Schulman diagnosed Plaintiff with traumatic low back derangement with mechanical lumbar discogenic pain and left lumbar radiculopathy. ( Id. ). Based on the Workers' Compensation guidelines, Schulman concluded that Jones had a marked partial disability in his lower back and that he was capable of doing only minimal sedentary work for two hours a day. (AR 263, 265).

In September and October 2007, Plaintiff saw Vasishtha twice more and told him that his "low back pain is now moderate in intensity at worst and averages between no pain to mild." (AR 221-23, 224-26). Vasishtha noted that Plaintiff's lumbar spine range of motion had improved, as had his motor strength. (AR 222-23, 225). Vasishtha continued to diagnose Plaintiff with herniated lumbar spine discs, and he opined that Plaintiff was "unable to work" due to a moderate partial disability. (AR 223-26). On November 1, 2007, Vasishtha administered a nerve root block injection to treat Plaintiff's pain. (AR 219-20). Schulman examined Plaintiff again on November 7, 2007, and repeated much of his examination findings and his diagnosis, and noted that Plaintiff's "prognosis is uncertain, " but that he would "estimate it to be poor to fair." (AR 260-62). On December 3, 2007, Vasishtha examined Plaintiff, who complained of moderate low back pain and discomfort when sitting for prolonged periods of time. (AR 216-18). Vasishtha repeated most of his previous findings and diagnosis, but noted that Plaintiff had lost twenty-five pounds through dieting and exercise. (AR 217-218).

On April 22, 2008, Nieves examined Plaintiff and diagnosed him with a lumbar strain with radicular features. (AR 370). He reported that Plaintiff was attending physical therapy twice each week and that medications were helping control his pain. ( Id. ). Plaintiff was next examined by Schulman on May 8, 2008, at which point Plaintiff complained of back pain and diminished sensation over the L4L5 and S1 dermatome area. (AR 257-59). Schulman found that Plaintiff's left ankle and knee reflexes were diminished, and he diagnosed him with chronic lumbar discogenic disease with left lumbar radiculopathy and marked weakness of the left lower extremity. ( Id. ). Schulman determined that Plaintiff could not return to work as a dock worker, but "could work minimal light duty work or sedentary work with no repetitive bending, lifting, pushing or pulling of more than 5 to 10 pounds" for two to four hours a day. ( Id. ).

On June 2, 2008, Vasishtha examined Plaintiff, who stated that he could walk only one city block, that he fell frequently, and that he had moderate to occasionally severe lower back pain that radiated to his left lower extremities. (AR 251-52, 387-89). Vasishtha rated Plaintiff's upper and lower extremities' motor strength as 5/5, except for his left "myotomal muscles, " which he rated 4- or 4 out of 5. (AR 389-90). Vasishtha opined that Plaintiff could not use public transportation, sit for extended periods of time, and needed help climbing stairs. ( Id. ). Nieves examined Plaintiff on June 17, 2008. Although he noted that Plaintiff was tolerating his medications, had "intact" sensations, and rated his motor power as 5/5, Nieves repeated his diagnosis of a lumbar strain with radicular features. (AR 367-68).

On December 29, 2008, Mustafa examined Plaintiff, who complained of persistent lower back pain, which was moderate in intensity. (AR 379-80). Mustafa's examination revealed that Plaintiff's muscle tone was within normal limits, but that he had decreased sensation over the left L5-S1 dermatome, tenderness in his lower back, and reduced active range of lumbar motion. (AR 380). Mustafa diagnosed Plaintiff with "lumbosacral disc herniation along with ...


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